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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
�- w� / Stata Fortr a3709 (RS / 4-03)
Presaibed Cy Department of Local Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor o! the county where the property is locareo.
Filing Dates: 1) Real PropeRy: Dunng fhe 12 months be%re May 11 0/ the year the deduction is to be eff�(qta�. 0 6�gj�d
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of fhe year lhe deduction ' be eNective.
See reverse side for additional instructions and qualifications.
Applicant( nerorcontractbuyer-see
C
Taxing Dis rid
���.�l.P/►'1
Assessed value of real property as of
March 1, curcent year
If no, what is his / her exaa share of
If name on record is different ihan th
'�me of mortgagee or contract seiic
Address of mortgagee or contrad s�
-���1-(�I•d��
ti s on reverse side)
..
ey number / legal escription
-ao •
Mortgage / Contrad indebtedness
March 1, current year
Record number
Page number
as of Is the applicant the sole legal or
owneR ❑ Yes ❑ No
gg,�a
/AA.27� f'✓ S �eone other than spouse, indicate with whom.
��,��i,�G �� Is the propeAy in question:
e�7� /� /1� _ ❑ Real Property O Mobile Hortie pC 67.
� (.r.i/�,
A .I �
03-����
Name of assignee or other owner or holder of mortgage
of assignee (numtier and stieet, city, state, ZIP code)
Does applicant own property in any other If yes, what county?
county in Indiana?
Deduclion approved in the amount of:
20 ��
\
Signature
� ;
�a �
What Taxing District?
COUNTY AUDITOR
20 0� 20 20
7
County Auditor
Has this dedudion been requested on
property for current yea(? � Yes 0 No
�
Date
20
certiy under the penalty of perjury lhat the above and foregoing information is true and corred and that the applicants was / were
lent of Indiana and owner of the atorementioned property on March 1, 20
full
of applicant
�
Person authorized by duly executed Power of Attomey
or by IC 6-7.1-12-.07
Address ofauthorized person